Running Head: SAFE TO BE HOME

Safe to Be Home: An Evidence-Based Look at the Safety of Homebirth Hollie S. Moyer Midwives College of Utah

Running Head: SAFE TO BE HOME For years, women have had to fight for the right to have their babies in the comfort of their homes. Facing social ostracism and ridicule from the medical community for allegedly endangering themselves and their babies, they are accused of being irresponsible mothers. New studies have shown the opposite to be true. For women with low-risk pregnancies, homebirth is

an option proven to be as safe as hospital birth, involving fewer interventions, resulting in greater maternal satisfaction, and overall better outcomes for baby and mother. This paper reviews five studies on the outcomes and safety of homebirth. These studies represent data from the Netherlands, England, Canada, and North America. They are varied in scope from an analysis by Durand (1992) of births done at The Farm, a small birth community headed by Ina May Gaskin in rural Tennessee, to large studies comparing the outcomes of planned low-risk homebirths and those in hospitals (Janssen, Saxell, Page, Klein, et al. , 2009; deJong, van der Goes, Ravelli, Amelink-Verburg , et al., 2009; Johnson and Davis, 2005) and one review by Rogers, Yearly, and Littlehales (2012) of a groundbreaking study in England on the safety of homebirth. The overwhelming consensus of all of these studies is a resounding Yes! to the safety of homebirth. The greatest incompatibility between planned hospital births and planned homebirths among low-risk women is the use of interventions. The common perception of hospital births as safer is only accurate in cases in which life-saving technology is needed immediately (Durand, 1992). This is uncommon among women with low-risk pregnancies. There is also evidence that unnecessary interventions frequently used in hospitals may increase the risk of adverse outcomes even in low-risk women (Durand, 1992). The greater use of interventions, especially unnecessary interventions, common in hospital births is an important factor in the degree of safety in childbirth.

Running Head: SAFE TO BE HOME In the Birthplace study done in England, Rogers, et al. (2012) say: Low-risk women who planned to give birth in a consultant-led unit are three times more likely to have an emergency cesarean section, more than twice as likely to have their baby delivered by forceps or vacuum extractor, twice as likely to need a blood transfusion and more likely to require admission to intensive care and have serious perineal trauma, compared to the low-risk women who chose birth at home or in a midwife-led unit. (p. 29) The other studies had similar results. Janssen, et al. (2009) showed that women planning homebirths were significantly less likely to experience electronic fetal monitoring, augmentation of labor, assisted vaginal delivery, cesarean section, and episiotomy (p. 379). Johnson and Davis (2005) found medical intervention for homebirths to be less than half as

frequent as those in hospital regardless of whether the comparison was between a low-risk group or the general population having hospital births (p. 2).
90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 33.0% 19.0% 9.6% 2.1% Electronic Fetal Monitoring Episiotomy 3.7% Cesarean Section 5.5% 0.6% Vacuum Extraction Hospital Home 84.3%

30.0%
20.0% 10.0% 0.0%

Chart 1. Hospital and Home birth use of interventions.

Running Head: SAFE TO BE HOME The above chart depicts the percentage use of electronic fetal monitoring, episiotomy, cesarean section, and vacuum extraction between planned, low-risk hospital births and planned, low-risk homebirths, based on the Johnson and Davis study. Overall, the data show that hospitals are increasingly unlikely places to experience normal, physiologic birth (Lothian, 2006). Clearly homebirth is associated with a better chance for a natural birth. One of the most prevalent misconceptions about homebirth is that it comes with an increased likelihood toward maternal and neonatal mortality or morbidity. However, these studies have shown similar rates of maternal and neonatal mortality and morbidity between homebirth and hospital birth for low-risk women in the United States (see Johnson and Davis, 2005). In fact, in the study done in the Netherlands by deJong, et al. (2009), babies of women who planned a homebirth were less likely to require admission to the NICU than those born to

women who planned a hospital birth (p. 1180). They were also less likely, according to Janssen, et al. (2009), to suffer from birth trauma, require resuscitation at birth, or need oxygen therapy beyond 24 hours. Outcomes of homebirth were even better for mothers. DeJong, et al. (2009) found that a planned homebirth did not increase the risks of perinatal mortality or severe perinatal morbidity among low-risk women. Furthermore, the study by Janssen, et al. (2009) showed that women were less likely to suffer from third or fourth degree perineal tears, postpartum hemorrhage, or pyrexia, concluding that The risk of all adverse maternal outcomes assessed was significantly lower among the women who planned a homebirth than among those who planned on physician attended hospital birth (p. 379). Repeatedly these studies have shown that homebirth is safe for low-risk women.

Running Head: SAFE TO BE HOME In addition to the issues of safety addressed above, at least two studies showed the great financial benefit of homebirth. In England, the Birthplace study by Rogers, et al. (2012), found that the cost of births for low-risk women in obstetric units was significantly higher [than those birthing at home or in birth centers] (p. 29). The financial analysis done by Johnson and Davis

(2005) in their North American study showed that an uncomplicated vaginal birth in hospital cost on average three times as much as similar birth at home with a midwife (p. 6). These findings have significance beyond the individual client. Based on this data, insurance companies, which almost exclusively cover only births in hospitals, could reduce the cost of their claims by offering to cover homebirths as well. Extrapolating from this it is not hard to see that homebirth has potential for economic benefit on a national level. The reasons for the positive outcomes of homebirth are several. Midwives thirst for growth and seek to improve their care by attention to and application of evidence-based knowledge (Smith, 2005, p. 748) rather than routine use of interventions. They are experts at normal birth and, therefore, know immediately when abnormalities arise. They provide continuous care for the woman throughout the childbearing cycle. Davis (1997) notes, Every birth has some potential for complications, but with continuity of care, the midwifes competence in handling these is facilitated both by foreknowledge of the mothers condition and by the mothers trust in her abilities. (p. 5) Midwives and their clients use shared-decision making to ensure maternal control that leads to greater maternal satisfaction. Additionally, the home environment is familiar and likely more conducive to natural birth (deJong, et al., 2009). In the event of an emergency, midwives are trained to manage the situation while acting on pre-determined transfer plans and never leaving the side of the woman until she is completely safe.

Running Head: SAFE TO BE HOME Hospitals have highlighted birth as a risky endeavor, exaggerated the small risks associated with birth, and created as Lothian (2006) says, risks where none existed before (p. 44). The concept of hospitals as safe and homes as unsafe is an illusion. These studies have assured the safety of planned homebirth for women with low-risk pregnancies attended by a trained midwife. Homebirth is associated with similar levels of maternal and neonatal mortality

or morbidity as hospital birth but with fewer interventions and greater maternal satisfaction. The United States should take note of and seek to follow the example of the Netherlands where maternity care is divided into primary care for low-risk women assisted by midwives at home or in a birth center without interventions, and secondary care for women with increased-risk in hospitals with physicians attending (deJong, et al., 2009). With increased discussion of the safety of homebirth, and sharing the amazing stories of women who give birth at home which are marked by strength, confidence, and joy (Lothian, 2006), women will find themselves free to choose and knowing they are safe to be home.

Running Head: SAFE TO BE HOME References deJonge, A., B. van der Goes, A. Ravelli, M. Amelink-Verburg, B. Mol, J. Nijhuis, J.

Bennebroek Gravenhorst, and S. Buitendijk. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG, 116, 1177-1184. Davis, E. (1997). Heart & hands: A midwifes guide to pregnancy and birth. Berkeley, California: Celestial Arts. Durand, A.M. (1992). The safety of home birth: The Farm study. American Journal of Public Health, 82(3), 450-453. Janssen, P.A., L. Saxell, L.A. Page, M.C. Klein, R.M. Liston, and S.K. Lee. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Canadian Medical Association Journal, 181(6-7), 377-383. Johnson, K.C. and B. Daviss. (2005). Outcomes of planned home births with certified professional midwives: Large prospective study in North America. British Midwifery Journal, 330(7505), 1416. Lothian, J.A. (2006). Home birth: The wave of the future? The Journal of Perinatal Education, 15(3), 43-46. Rogers, C., C. Yearly, and C. Littlehales. (2012). The birthplace study: Turning the tide of childbirth. British Journal of Midwifery, 20(1), 28-33. Smith, N. (2005, December). Individualized care will help promote social inclusion. British Journal of Midwifery, 13(12), 748.